Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Work Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred method of correspondence

Email
Phone

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone

Pet information #1

We want to learn all about your pet!

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Please name medication, dosage, and frequency (write "none" if not applicable) *

Please name flea, tick, and/or heartworm preventative medication (write "none" if not applicable) *

Please contact your previous veterinarian and request complete medical history. We require animal's history 72 hours prior to appointment time. *

I will contact my previous vet
I do not have a previous vet

Previous vet's name and phone number *

Do you want to add another pet? *

Yes
No

Pet information #2

We want to learn all about your pet!

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Please name medication, dosage, and frequency (write "none" if not applicable) *

Please name flea, tick, and/or heartworm preventative medication (write "none" if not applicable) *

Please contact your previous veterinarian and request complete medical history. We require animal's history 72 hours prior to appointment time. *

I will contact my previous vet
I do not have a previous vet

Previous vet's name and phone number *

Do you want to add another pet? *

Yes
No

Pet information #3

We want to learn all about your pet!

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Please name medication, dosage, and frequency (write "none" if not applicable) *

Please name flea, tick, and/or heartworm preventative medication (write "none" if not applicable) *

Please contact your previous veterinarian and request complete medical history. We require animal's history 72 hours prior to appointment time. *

I will contact my previous vet
I do not have a previous vet

Previous vet's name and phone number *

"Ruff"eral Section *

Please specify *

Financial Policy Acknowledgement

We thank you for entrusting us with the care of your pet. In order to provide the best possible animal care, we require that all professional fees be due at the time of service. We accept cash and credit cards including Visa, MasterCard, American Express, and Discover. We also accept Care Credit.

WE REQUIRE IMMEDIATE PAYMENT FOR SERVICES RENDERED OR MEDICATION PRESCRIPTIONS FULFILLED ON SITE.

I hereby authorize the doctor and technicians to administer services and treatment as explained to me by the doctor. I assume all financial responsibility for all charges incurred for the care and treatment of my pet(s). I understand that services are to be paid for when rendered.

At my request, I will receive a written estimate for services beyond routine care, which I may decline for any reason.

Check box to acknowledge *

I acknowledge and authorize

Schedule Policy Acknowledgement

At Charm City Veterinary Hospital, your scheduled appointment time is reserved exclusively for you and your pet. Charm City does not overbook appointment times. We believe optimal veterinary care can be provided only if we have enough time set aside to adequately examine and diagnose your pet, then discuss treatment options in detail with you.

We will make every effort to accommodate your scheduling needs. In return, we ask that you help us by keeping your scheduled appointments by arriving on time. If a situation arises that you will be late or not able to attend your appointment please let us know ASAP. When Charm City Vet receives advanced notice of cancellations, we are able to accommodate other patients needing care. Failure to comply with this policy will necessitate the assessment of the following fees:

You will receive an email stating that you missed an appointment and that you have been charged a Missed Appointment Fee ($60.00). In addition, when making future appointments the office visit fee must be paid at the time you schedule the appointment.

Check box to acknowledge *

I acknowledge

Late Arrival Policy

Appointments involving clients arriving more than ten minutes late may be considered "Missed Appointments" and may need to be rescheduled. If you think you are going to be late for your appointment, please call us to determine if your late arrival can be accommodated or if you will need to reschedule.

ALL ABOVE FEES WILL BE ASSESSED PER PET IN CASES OF MULTIPLE PET APPOINTMENTS.

Check box to acknowledge *

I acknowledge

Social Media Release

I, the undersigned owner or authorized agent for the owner of the above pet, acknowledge that photos of my pet(s) may be used on Charm City Veterinary Hospital's (CCVH) official media sites. These sites include but are not limited to :

• Facebook
• Instagram
• Twitter
• CCVH's official website

I understand that this information may be used in electronic publications, audio/visual presentations, promotional literature and/or similar ways. My consent is freely given to CCVH with no expectations of payment or royalties. I release CCVH from any and all liability which may arise from the use of such promotional materials, video and/or photographs.

Do you authorize? *

I authorize
I do not authorize

Please type in your Instagram handles

Additional Comments

Please use the space below to share any additional information about your pet(s) you deem applicable. Thanks!!!

Write your comments here:

New Client Form

Pet information #1

Pet information #2

Pet information #3

Financial Policy Acknowledgement

Schedule Policy Acknowledgement

Late Arrival Policy

Social Media Release

Additional Comments

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